Epistaxis in Bright's disease due to a sanguine dyscrasia, to alterations of the vessels supplying the nasal mucous mem brane, to cardiac hypertrophy, and to increased arterial tension. Occurs most frequently in the interstitial form of Bright's disease, and is apt to appear principally at the beginning and at the end of the malady. Sometimes it is the first sign which excites a suspicion of the affection. Saverny (These de Paris, '91).
Conditions in which hemorrhage may occur in Bright's disease: high tension, modifications in the structure of the arteries, and hypertrophy of the heart. Potain (Jour. de Mad. et de Chir. Pra tiques, Aug. 10, '94).
Importance of hemorrhage from the nose and into the ear as early manifes- • tations of Bright's disease. Illustrative case. The so-called cases of spontaneous or idiopathic hemorrhages into the ear ought all to be carefully investigated as to the possibility of an underlying ne phritic cause. He would speak of a tym panitis or myringitis albuminurica, just as we speak of rhinitis albuminurica. Haug (Deutsche med. Woch., Nov. 5, '96).
Sudden cedema of the larynx may also supervene, and is always a grave condi tion. Transudations into the pleural sac (hydrothorax) and the lungs may pre cede the fatal termination. Dyspncea is either urwmic or cardiac and is usually worse at night; a true orthopncea, with Cheyne-Stokes breathing, may be ob served in association with urwmic stupor and coma, and near the end of the pa tient's life.
The signs of hypertrophy of the heart (particularly of the left ventricle) may be elicited, though symptoms referable to the heart itself are absent, unless dila tation and feebleness, sudden arterial contraction, or endocarditis occur. In spection and palpation show the apex beat to be displaced downward and to the left, and the impulse to be increased, heaving, and rather circumscribed. In cases of co-existing emphysema, and later, when dilatation may eclipse the hypertrophy, these signs may become less evident. The left border of deep cardiac dullness extends outside the nipple-line in the fifth or sixth inter space. The first sound of the heart is loud and may be reduplicated. Accent uation of the aortic second sound is a distinctive sign, and indicates increased vascular tension; it may have a metallic quality in some cases. There may also develop a mitral systolic murmur as the result of relative insufficiency. There is
increased tension of the pulse, the latter being hard, persistent, and incompress ible; the pulse-wave is also increased in duration (pulsus tardus). Most of the palpable arteries are hard, thickened, and tortuous, owing to the arterioscle rosis. As soon as compensation fails, symptoms of breathlessness on exertion, palpitation, and the like, appear; often these occur in paroxysms and constitute "cardiac asthma." The resulting stasis causes a transudation into the lungs (bronchorrhcea, pulmonary cedema) and later to cedema of the extremities.
Of 106 fatal cases of chronic (intersti tial) nephritis, 20 died from cerebral hemorrhage; in all of these cases both kidneys were diseased, cedema of the extremities not being recorded in a single instance and oedema of the lungs in only 2, thus showing that all was going on well until the fatal rupture. The re maining eases died from oedema, princi pally involving the lungs and pleurm.
CEdeina is, therefore, the most common cause of death; this occurs in conse quence of the stretching of the auriculo ventricular orifice, allowing of regurgi tation. A mitral murmur is by no means always present. Arterial sclerosis is marked in the cases dying from cere bral hemorrhage, and this might ac count for the non-dilatation of the au riculo-ventricular orifices. The heart sounds assumed a clanging tone in sev eral instances preceding the fatal result observed. Hawkins and Russell Dodd (Clinical Soc. of London; Annual, '94).
Since they are indicative, as a rule, of grave urmmia, the symptoms referable tc the nervous system are of great im portance. There may be neuralgic pains throughout the body, and insomnia, and cephalalgia is frequent. Later great drowsiness is often a premonition of urcemic coma. Muscular twitchings may precede convulsions, and should attract attention to the imminent danger. Cere bral apoplexy with hemiplegia may form the first symptom of contracted kidney, and is apt to occur in cases of marked hardening and weakening of the arteries. Hmmorrhagic pachymeningitis and haem orrhage into the brain-substance may occur. The hemiplegia may last until the end, or it may disappear soon and be followed by subsequent attacks at intervals. Dieulafoy believes numb ness, formication, and pallor of the fin gers ("dead finger") to be sometimes the earliest symptoms of chronic Bright's disease.